Is the phone call the most effective method for recall in cervical cancer screening?--results from a randomised control trial

Electronic Health Interventions and Cervical Cancer Screening: Systematic Review and Meta-Analysis

BACKGROUND

Cervical cancer is a significant cause of mortality in women. Although screening has reduced cervical cancer mortality, screening rates remain suboptimal. Electronic health interventions emerge as promising strategies to effectively tackle this issue.

OBJECTIVE

This systematic review and meta-analysis aimed to determine the effectiveness of electronic health interventions in cervical cancer screening.

METHODS

On December 29, 2023, we performed an extensive search for randomized controlled trials evaluating electronic health interventions to promote cervical cancer screening in adults. The search covered multiple databases, including MEDLINE, the Cochrane Central Registry of Controlled Trials, Embase, PsycINFO, PubMed, Scopus, Web of Science, and the Cumulative Index to Nursing and Allied Health Literature. These studies examined the effectiveness of electronic health interventions on cervical cancer screening. Studies published between 2013 and 2022 were included. Two independent reviewers evaluated the titles, abstracts, and full-text publications, also assessing the risk of bias using the Cochrane Risk of Bias 2 tool. Subgroup analysis was conducted based on subjects, intervention type, and economic level. The Mantel-Haenszel method was used within a random-effects model to pool the relative risk of participation in cervical cancer screening.

RESULTS

A screening of 713 records identified 14 articles (15 studies) with 23,102 participants, which were included in the final analysis. The intervention strategies used in these studies included short messaging services (4/14), multimode interventions (4/14), phone calls (2/14), web videos (3/14), and internet-based booking (1/14). The results indicated that electronic health interventions were more effective than control interventions for improving cervical cancer screening rates (relative risk [RR] 1.464, 95% CI 1.285-1.667; P<.001; I2=84%), cervical cancer screening (intention-to-treat) (RR 1.382, 95% CI 1.214-1.574; P<.001; I2=82%), and cervical cancer screening (per-protocol; RR 1.565, 95% CI 1.381-1.772; P<.001; I2=74%). Subgroup analysis revealed that phone calls (RR 1.82, 95% CI 1.40-2.38), multimode (RR 1.62, 95% CI 1.26-2.08), SMS (RR 1.41, 95% CI 1.14-1.73), and video- and internet-based booking (RR 1.25, 95% CI 1.03-1.51) interventions were superior to usual care. In addition, electronic health interventions did not show a statistically significant improvement in cervical cancer screening rates among women with HPV (RR 1.17, 95% CI 0.95-1.45). Electronic health interventions had a greater impact on improving cervical cancer screening rates among women in low- and middle-income areas (RR 1.51, 95% CI 1.27-1.79). There were no indications of small study effects or publication bias.

CONCLUSIONS

Electronic health interventions are recommended in cervical cancer screening programs due to their potential to increase participation rates. However, significant heterogeneity remained in this meta-analysis. Researchers should conduct large-scale studies focusing on the cost-effectiveness of these interventions.

TRIAL REGISTRATION

CRD42024502884; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=502884.

Health Behavior Change Interventions Using Mobile Phones: A Meta-Analysis

The technological capabilities of mobile phones have made them a useful tool for delivering interventions, but additional research is needed to determine the mechanisms underlying the comparative effectiveness of mobile health interventions. This meta-analysis analyzes the relative effectiveness of mobile phone-based health interventions relative to comparison/control groups (e.g., eHealth interventions, standard of care, etc.), the utility of the theory of planned behavior in mobile phone-based health interventions, and the roles of various moderators. One hundred eighteen studies met inclusion criteria and contributed to an overall effect size of d = 0.27 (95% CI [.22, .32]). Findings indicate that mobile phone-based health interventions are significantly more effective than comparison/control conditions at improving health behaviors. Additionally, perceived behavioral control was a significant moderator providing some support for the usefulness of theory of planned behavior in mobile phone-based health interventions.

Confusion and anxiety in between abnormal cervical cancer screening results and colposcopy: "The land of the unknown"

OBJECTIVE

Attendance to colposcopy after abnormal cervical cancer screening is essential to cervical cancer prevention. This qualitative study explored patients' understanding of screening results, their experiences of the time leading up to the colposcopy appointment, and colposcopy.

METHODS

We recruited women referred for colposcopy from two urban practices in an academic health system. Individual interviews (N = 15) with participants were conducted after colposcopy appointments about their cervical cancer screening histories, current results, and colposcopy experiences. A team analyzed and summarized interviews and coded transcripts in Atlas.ti.

RESULTS

We found that most women were confused about their screening results, did not know what a colposcopy was before being referred for one, and experienced anxiety in the interval between receiving their results and having their colposcopy. Most women searched for information online, but found "misinformation," "worst-case scenarios" and generic information that did not resolve their confusion.

CONCLUSION

Women had little understanding of their cervical cancer risk and experienced anxiety looking for information and waiting for the colposcopy. Educating patients about cervical precancer and colposcopy, providing tailored information about their abnormal screening test results and potential next steps, and helping women manage distress may alleviate uncertainty while waiting for follow-up appointments.

PRACTICE IMPLICATIONS

Interventions to manage uncertainty and distress in the interval between receiving an abnormal screening test result and attending colposcopy are needed, even among highly adherent patients.

The State of Cancer Care in the United Arab Emirates in 2022

Cancer is the third-leading cause of death in the United Arab Emirates (UAE); cancer care in the UAE has evolved dramatically over the last 40 years, from a single center in Al Ain in 1981 to more than 30 cancer centers and clinics across the UAE, with at least four comprehensive cancer centers in the UAE nowadays. Despite the significant progress in medical care, cancer quality control across the UAE is still lacking, with significant variations in cancer care across the cancer centers. Access to clinical trials is still hampered by a lack of expertise and research infrastructure and a small population, which renders patient accrual for trials a major challenge. Education and training are other areas for improvement that require immediate attention, and, in this review, we try to address these critical aspects for stakeholders to consider better cancer care in the UAE. Early cancer detection and screening are still evolving in the UAE, and a national screening program is lacking. There is also a need to address barriers to screening and to consider less invasive screening methods such as approved blood-based screening, which is likely to be more acceptable to the UAE population. In this review, we also address new topics that have not been addressed previously, including oncology medical tourism, psycho-oncology, onco-fertility, precision oncology, survivorship, oncology nursing, cancer support programs, and the oncology sector's response to the COVID-19 pandemic, all in the context of the UAE cancer landscape. Finally, we provide recommendations for policymakers, regulators, payers, patient advocacy groups, and the UAE oncology community regarding the delivery and future planning of high-quality cancer care. These recommendations are aligned with the UAE government's vision to reduce cancer mortality and provide high-quality healthcare for its citizens and residents.

The Effects of Theory-Based Educational Intervention and WhatsApp Follow-up on Papanicolaou Smear Uptake Among Postnatal Women in Malaysia: Randomized Controlled Trial

Background

Despite the availability and accessibility of free Papanicolaou (Pap) smear as a screening tool for cervical cancer, the uptake of Pap smear in Malaysia has not changed in the last 15 years. Previous studies have shown that the high uptake of Pap smear reduces the mortality rate of patients with cervical cancer. The low uptake of Pap smear is multifactorial, and the problem could be minimized through the use of mobile technologies. Nevertheless, most intervention studies focused on individual factors, while other important aspects such as mobile technologies, especially WhatsApp, have not been investigated yet.

Objective

This study aims to determine the effects of a theory-based educational intervention and WhatsApp follow-up (Pap smear uptake [PSU] intervention) in improving PSU among postnatal women in Seremban, Negeri Sembilan, Malaysia.

Methods

A 2-arm, parallel single-blind cluster randomized controlled trial was conducted among postpartum women from the Seremban district. Twelve health clinics were randomly assigned to the intervention and control groups. At baseline, both groups received a self-administered questionnaire. The intervention group received standard care and PSU intervention delivered by a researcher. This 2-stage intervention module was developed based on Social Cognitive Theory, where the first stage was conducted face-to-face and the second stage included a WhatsApp follow-up. The control group received standard care. Participants were observed immediately and at 4, 8, and 12 weeks after the intervention. The primary endpoint was PSU, whereas the secondary endpoints were knowledge, attitude, and self-efficacy scores for Pap smear screening self-assessed using a Google Forms questionnaire. A generalized mixed model was used to determine the effectiveness of the intervention. All data were analyzed using IBM SPSS (version 25), and P value of .05 was considered statistically significant.

Results

We analyzed 401 women, of whom 76 (response rate: 325/401, 81%) had withdrawn because of the COVID-19 pandemic, with a total of 162 respondents in the intervention group and 163 respondents in the control group. The proportion of Pap smears at the 12-week follow-up was 67.9% (110/162) in the intervention group versus 39.8% (65/163) in the control group (P<.001). Significant differences between the intervention and control groups were found for Pap smear use (F_4,1178; P<.001), knowledge scores (F_4,1172=14.946; P<.001), attitude scores (F_4,1172=24.417; P<.001), and self-efficacy scores (F_1,1172=10.432; P<.001).

Conclusions

This study demonstrated that the PSU intervention is effective in increasing the uptake of Pap smear among postnatal women in Seremban district, Malaysia. This intervention module can be tested in other populations of women.

Trial Registration

Thai Clinical Trials Registry TCTR20200205001; https://www.thaiclinicaltrials.org/show/TCTR20200205001

The effect of multiple ınterventions for women at risk for cervical cancer on their health responsibility, beliefs regarding cervical cancer and having screening: a randomized controlled trial

This study was intended to analyze the effect of multiple initiations on beliefs about cervical cancer, health responsibility, and screening participation. In total, 134 women aged 40-55 years, who were at risk of cervical cancer and had never had a Pap smear before, were randomly assigned to the experimental (n = 67) and control (n = 67) groups. The 14 weeks of sessions involving the experimental group included group training on cervical cancer, counselling, reminder phone calls and delivery materials, all aimed to increase motivation to be screened regularly for cervical cancer. The control group received the usual care. The study data were collected using an information form, the Health Belief Model Scale, the Healthy Lifestyle Behaviors Scale II and the Assessment Form for Undergoing Pap-Smear Test. After the multiple interventions, there was a significant difference between the experimental and control group's Health Responsibility, Pap smear benefit and motivation, obstacle and health motivation scores (P < 0,05). The participation rate of women in the experimental group to cervical cancer screening was found to be 93%. Multiple nursing interventions (group training, counselling, reminder phone calls and delivery materials) were effective in increasing participation in cervical cancer screening programs.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical screening.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology.

MAIN RESULTS

Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard screening invitation, which would incur a fee, or an invitation offering screening free of charge. No difference in the uptake at 90 days was found (574/1562 intervention versus 612/1562 control, (RR 0.94, 95% CI: 0.86 to 1.03). The use of HPV self-testing as an alternative to conventional screening may also be effective at increasing uptake and this will be covered in a subsequent review. Secondary outcomes, including cost data, were incompletely documented. The majority of cluster-RCTs did not account for clustering or adequately report the number of clusters in the trial in order to estimate the design effect, so we did not selectively adjust the trials. It is unlikely that reporting of these trials would impact the overall conclusions and robustness of the results. Of the meta-analyses that could be performed, there was considerable statistical heterogeneity, and this should be borne in mind when interpreting these findings. Given this and the low to moderate evidence, further research may change these findings. The risk of bias in the majority of trials was unclear, and a number of trials suffered from methodological problems and inadequate reporting. We downgraded the certainty of evidence because of an unclear or high risk of bias with regards to allocation concealment, blinding, incomplete outcome data and other biases.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence to support the use of invitation letters to increase the uptake of cervical screening. Low-certainty evidence showed lay health worker involvement amongst ethnic minority populations may increase screening coverage, and there was also support for educational interventions, but it is unclear what format is most effective. The majority of the studies were from developed countries and so the relevance of low- and middle-income countries (LMICs), is unclear. Overall, the low-certainty evidence that was identified makes it difficult to infer as to which interventions were best, with exception of invitational interventions, where there appeared to be more reliable evidence.

Using a Frontline Staff Intervention to Improve Cervical Cancer Screening in a Large Academic Internal Medicine Clinic

BACKGROUND

Cervical cancer is the third most common malignancy affecting women. Screening with Papanicolaou (Pap) tests effectively identifies precancerous lesions and early-stage cervical cancer. While the nationwide rate of cervical cancer screening (CCS) is 84%, our urban general internal medicine (GIM) clinic population had a CCS rate of 70% in 2016.

OBJECTIVE

To improve our clinic's CCS rate to match or exceed the national average within 18 months by identifying barriers and testing solutions.

DESIGN

A quality improvement project led by a multidisciplinary group of healthcare providers.

PARTICIPANTS

Our GIM clinic includes 16 attending physicians, 116 resident physicians, and 20 medical assistants (MAs) with an insured and underserved patient population.

INTERVENTION

Phase 1 lasted 9 months and implemented CCS patient outreach, patient financial incentives, and clinic staff education. Phase 2 lasted 9 months and involved a workflow change in which MAs identified candidates for CCS during patient check-in. Feedback spanned the entire study period.

MAIN MEASURES

Our primary outcome was the number of Pap tests completed per month during the 2 study phases. Our secondary outcome was the clinic population's CCS rate for all eligible clinic patients.

KEY RESULTS

After interventions, the average number of monthly Pap tests increased from 35 to 56 in phase 1 and to 75 in phase 2. Of 385 patients contacted in phase 1, 283 scheduled a Pap test and 115 (41%) completed it. Compared to baseline, both interventions improved cervical cancer screening (phase 1 relative risk, 1.86; 95% CI, 1.64-2.10; P < 0.001; phase 2 relative risk, 2.70; 95% CI, 2.40-3.02; P < 0.001). Our clinic's CCS rate improved from 70% to 75% after the 18-month intervention.

CONCLUSIONS

The rate of CCS increased by 5% after a systematic 2-phase organizational intervention that empowered MAs to remind, identify, and prepare candidates during check-in for CCS.

The effect of educational program based on beliefs, subjective norms and perceived behavior control on doing pap-smear test in sample of Iranian women

Objective

Cervical cancer is considered treatable as long as it is detected early and managed effectively. Pap smear test is a screening tool that plays an important role in the early detection, prevention and can prevent any early cervical cell changes from becoming cancer. This study aims to survey the effect of educational programs based on beliefs, subjective norms, and perceived behavior control on doing the pap-smear test in a sample of Iranian women.

Materials and methods

This experimental interventional study was performed on 300 women admitted to Fasa City, Fars Province, Iran health centers in 2018–2019. A questionnaire consisting of demographic information, knowledge, Health Belief Model, and Theory of Planned Behavior constructs were used to measure on doing of Pap smear test in women before and after 6 months’ educational intervention.

Results

The results revealed that 6 months after the intervention, 108 women (72%) in the experimental group and only 9 women (6%) in the control group received the Pap smear test.

Conclusions

The current research results revealed that education based on the combination of the health Belief model and theory of planned behavior might be promoting participation and an increasing rate of receiving Pap smear tests in women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01419-w.

Social Media and mHealth Technology for Cancer Screening: Systematic Review and Meta-analysis

BACKGROUND

Cancer is a leading cause of death, and although screening can reduce cancer morbidity and mortality, participation in screening remains suboptimal.

OBJECTIVE

This systematic review and meta-analysis aims to evaluate the effectiveness of social media and mobile health (mHealth) interventions for cancer screening.

METHODS

We searched for randomized controlled trials and quasi-experimental studies of social media and mHealth interventions promoting cancer screening (breast, cervical, colorectal, lung, and prostate cancers) in adults in MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Communication & Mass Media Complete from January 1, 2000, to July 17, 2020. Two independent reviewers screened the titles, abstracts, and full-text articles and completed the risk of bias assessments. We pooled odds ratios for screening participation using the Mantel-Haenszel method in a random-effects model.

RESULTS

We screened 18,008 records identifying 39 studies (35 mHealth and 4 social media). The types of interventions included peer support (n=1), education or awareness (n=6), reminders (n=13), or mixed (n=19). The overall pooled odds ratio was 1.49 (95% CI 1.31-1.70), with similar effect sizes across cancer types.

CONCLUSIONS

Screening programs should consider mHealth interventions because of their promising role in promoting cancer screening participation. Given the limited number of studies identified, further research is needed for social media interventions.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42019139615; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=139615.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2019-035411.

Mobile Technologies and Cervical Cancer Screening in Low- and Middle-Income Countries: A Systematic Review

PURPOSE

Cervical cancer screening is not well implemented in many low- and middle-income countries (LMICs). Mobile health (mHealth) refers to utilization of mobile technologies in health promotion and disease management. We aimed to qualitatively synthesize published articles reporting the impact of mHealth on cervical cancer screening–related health behaviors.

METHODS

Three reviewers independently reviewed articles with the following criteria: the exposure or intervention of interest was mHealth, including messages or educational information sent via mobile telephone or e-mail; the comparison was people not using mHealth technology to receive screening-related information, and studies comparing multiple different mHealth interventional strategies were also eligible; the primary outcome was cervical cancer screening uptake, and secondary outcomes included awareness, intention, and knowledge of screening; appropriate research designs included randomized controlled trials and quasi-experimental or observational research; and the study was conducted in an LMIC.

RESULTS

Of the 8 selected studies, 5 treated mobile telephone or message reminders as the exposure or intervention, and 3 compared the effects of different messages on screening uptake. The outcomes were diverse, including screening uptake (n = 4); health beliefs regarding the Papanicolaou (Pap) test (n = 1); knowledge of, attitude toward, and adherence to colpocytologic examination (n = 1); interest in receiving messages about Pap test results or appointment (n = 1); and return for Pap test reports (n = 1).

CONCLUSION

Overall, our systematic review suggests that mobile technologies, particularly telephone reminders or messages, lead to increased Pap test uptake; additional work is needed to unequivocally verify whether mhealth interventions can improve knowledge regarding cervical cancer. Our study will inform mHealth-based interventions for cervical cancer screening promotion in LMICs.

Digital Health Strategies for Cervical Cancer Control in Low- and Middle-Income Countries: Systematic Review of Current Implementations and Gaps in Research

BACKGROUND

Nearly 90% of deaths due to cervical cancer occur in low- and middle-income countries (LMICs). In recent years, many digital health strategies have been implemented in LMICs to ameliorate patient-, provider-, and health system-level challenges in cervical cancer control. However, there are limited efforts to systematically review the effectiveness and current landscape of digital health strategies for cervical cancer control in LMICs.

OBJECTIVE

We aim to conduct a systematic review of digital health strategies for cervical cancer control in LMICs to assess their effectiveness, describe the range of strategies used, and summarize challenges in their implementation.

METHODS

A systematic search was conducted to identify publications describing digital health strategies for cervical cancer control in LMICs from 5 academic databases and Google Scholar. The review excluded digital strategies associated with improving vaccination coverage against human papillomavirus. Titles and abstracts were screened, and full texts were reviewed for eligibility. A structured data extraction template was used to summarize the information from the included studies. The risk of bias and data reporting guidelines for mobile health were assessed for each study. A meta-analysis of effectiveness was planned along with a narrative review of digital health strategies, implementation challenges, and opportunities for future research.

RESULTS

In the 27 included studies, interventions for cervical cancer control focused on secondary prevention (ie, screening and treatment of precancerous lesions) and digital health strategies to facilitate patient education, digital cervicography, health worker training, and data quality. Most of the included studies were conducted in sub-Saharan Africa, with fewer studies in other LMIC settings in Asia or South America. A low risk of bias was found in 2 studies, and a moderate risk of bias was found in 4 studies, while the remaining 21 studies had a high risk of bias. A meta-analysis of effectiveness was not conducted because of insufficient studies with robust study designs and matched outcomes or interventions.

CONCLUSIONS

Current evidence on the effectiveness of digital health strategies for cervical cancer control is limited and, in most cases, is associated with a high risk of bias. Further studies are recommended to expand the investigation of digital health strategies for cervical cancer using robust study designs, explore other LMIC settings with a high burden of cervical cancer (eg, South America), and test a greater diversity of digital strategies.

Behavioral economics informed message content in text message reminders to improve cervical screening participation: Two pragmatic randomized controlled trials

The objective of the reported research was to assess the impact of text message (SMS) reminders and their content on cervical screening rates. Women invited for cervical screening in Northwest London from February-October 2015 were eligible. 3133 women aged 24-29 (Study 1) were randomized (1, 1) to 'no SMS' (control), or a primary care physician (PCP) endorsed SMS (SMS-PCP). 11,405 women aged 30-64 (Study 2), were randomized (1, 1:1:1:1:1:1) to either: no SMS, an SMS without manipulation (SMS), the SMS-PCP, an SMS with a total or proportionate social norm (SMS-SNT or SMS-SNP), or an SMS with a gain-framed or loss-framed message (SMS-GF and SMS-LF). The primary outcome was participation at 18 weeks. In Study 1 participation was significantly higher in the SMS-PCP arm (31.4%) compared to control (26.4%, aOR, 1.29, 95%CI: 1.09-1·51; p = 0.002). In Study 2 participation was highest in the SMS-PCP (38.4%) and SMS (38.1%) arms compared to control (34.4%), (aOR: 1.19, 95%CI: 1.03-1.38; p = 0.02 and aOR: 1.18, 95%CI: 1.02-1.37; p = 0.03, respectively). The results demonstrate that behavioral SMSs improve cervical screening participation. The message content plays an important role in the impact of SMS. The results from this trial have already been used to designing effective policy for cervical cancer screening. The NHS Cervical Screening Programme started running a London-wide screening SMS campaign which was based on the cervical screening trial described here. According to figures published by Public Health England, after six months attendance increased by 4.8%, which is the equivalent of 13,400 more women being screened at 18 weeks.

Innovative prototypes for cervical cancer prevention in low-income primary care settings: A human-centered design approach

This article presents the design process of innovative prototypes for cervical cancer prevention in primary care centers located in low-income settings in Cali, Colombia, using the Human-Centered Design (HCD). The project was developed in collaboration with a public healthcare network comprised of 38 urban and rural centers with women between the ages of 25 and 65 years, healthcare providers of the cancer program, healthcare administrators and the general manager of said network. Our HCD process involved five stages: research, need synthesis, ideation and co-design process, prototyping and in-context usability testing. In practice, some of the stages are overlapped and iterated throughout the design process. We conducted observations, open-ended interviews and conversations, multi-stakeholder workshops, focus groups, systematic text condensation analyses and tests in real contexts. As a result, we designed four prototypes: (1) 'Encanto': An educational manicure service, (2) 'No le des la espalda a la citología': A media-based strategy, (3) An educational wireless queuing device in the waiting room, and (4) Citobot: A cervical cancer early detection device, system, and method. The tests carried out with each prototype showed their value, limitations and possibilities in terms of subsequent development and validation through public health research or clinical research. We recognize that a longer-term evaluation is required in order to determine whether the prototypes will be used regularly, integrated into cervical cancer screening services and effectively improve access to cytology as a screening test. We conclude that HCD is a useful for design-based prevention in the field of cervical cancer. The integration of this approach with public health research would allow the generation of evidence during to the formulation of policies and programs as well as optimize existing interventions and, ultimately, facilitate the scalability and financing of what actually works.

Effectiveness of Mass and Small Media Campaigns to Improve Cancer Awareness and Screening Rates in Asia: A Systematic Review

PURPOSE

The main objective of this systematic review was to identify whether mass and small media interventions improve knowledge and attitudes about cancer, cancer screening rates, and early detection of cancer in Asia.

METHODS

The review was conducted according to a predefined protocol. Medline, EMBASE, CINAHL, Web of Science, Cochrane Library, and Google Scholar were searched in September 2017, and data extraction and rating of methodologic study quality (according to Joanna Briggs Institute rating procedures) were performed independently by reviewers.

RESULTS

Twenty-two studies (reported across 24 papers) met the inclusion criteria. Most studies (n = 21) were conducted in high or upper-middle income countries; targeted breast (n = 11), cervical (n = 7), colorectal (n = 3), or oral (n = 2) cancer; and used small media either alone (n = 15) or in combination with mass media and other components (n = 5). Studies regarding cancer screening uptake were of medium to high quality and mainly reported positive outcomes for cervical cancer and mixed results for breast and colorectal cancer. The methodologic strength of research that investigated change in cancer-related knowledge and the cost effectiveness of interventions, respectively, were weak and inconclusive.

CONCLUSION

Evidence indicated that small media campaigns seemed to be effective in terms of increasing screening uptake in Asia, in particular cervical cancer screening. Because of the limited number of studies in Asia, it was not possible to be certain about the effectiveness of mass media in improving screening uptake and the effectiveness of campaigns in improving cancer-related knowledge.

Targeted client communication via mobile devices for improving sexual and reproductive health

BACKGROUND

The burden of poor sexual and reproductive health (SRH) worldwide is substantial, disproportionately affecting those living in low- and middle-income countries. Targeted client communication (TCC) delivered via mobile devices (MD) (TCCMD) may improve the health behaviours and service use important for sexual and reproductive health.

OBJECTIVES

To assess the effects of TCC via MD on adolescents' knowledge, and on adolescents' and adults' sexual and reproductive health behaviour, health service use, and health and well-being.

SEARCH METHODS

In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.

SELECTION CRITERIA

We included randomised controlled trials of TCC via MD to improve sexual and reproductive health behaviour, health service use, and health and well-being. Eligible comparators were standard care or no intervention, non-digital TCC, and digital non-targeted communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second. We have presented results separately for adult and adolescent populations, and for each comparison.

MAIN RESULTS

We included 40 trials (27 among adult populations and 13 among adolescent populations) with a total of 26,854 participants. All but one of the trials among adolescent populations were conducted in high-income countries. Trials among adult populations were conducted in a range of high- to low-income countries. Among adolescents, nine interventions were delivered solely through text messages; four interventions tested text messages in combination with another communication channel, such as emails, multimedia messaging, or voice calls; and one intervention used voice calls alone. Among adults, 20 interventions were delivered through text messages; two through a combination of text messages and voice calls; and the rest were delivered through other channels such as voice calls, multimedia messaging, interactive voice response, and instant messaging services. Adolescent populations TCCMD versus standard care TCCMD may increase sexual health knowledge (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.23 to 1.71; low-certainty evidence). TCCMD may modestly increase contraception use (RR 1.19, 95% CI 1.05 to 1.35; low-certainty evidence). The effects on condom use, antiretroviral therapy (ART) adherence, and health service use are uncertain due to very low-certainty evidence. The effects on abortion and STI rates are unknown due to lack of studies. TCCMD versus non-digital TCC (e.g. pamphlets) The effects of TCCMD on behaviour (contraception use, condom use, ART adherence), service use, health and wellbeing (abortion and STI rates) are unknown due to lack of studies for this comparison. TCCMD versus digital non-targeted communication The effects on sexual health knowledge, condom and contraceptive use are uncertain due to very low-certainty evidence. Interventions may increase health service use (attendance for STI/HIV testing, RR 1.61, 95% CI 1.08 to 2.40; low-certainty evidence). The intervention may be beneficial for reducing STI rates (RR 0.61, 95% CI 0.28 to 1.33; low-certainty evidence), but the confidence interval encompasses both benefit and harm. The effects on abortion rates and on ART adherence are unknown due to lack of studies. We are uncertain whether TCCMD results in unintended consequences due to lack of evidence. Adult populations TCCMD versus standard care For health behaviours, TCCMD may modestly increase contraception use at 12 months (RR 1.17, 95% CI 0.92 to 1.48) and may reduce repeat abortion (RR 0.68 95% CI 0.28 to 1.66), though the confidence interval encompasses benefit and harm (low-certainty evidence). The effect on condom use is uncertain. No study measured the impact of this intervention on STI rates. TCCMD may modestly increase ART adherence (RR 1.13, 95% CI 0.97 to 1.32, low-certainty evidence, and standardised mean difference 0.44, 95% CI -0.14 to 1.02, low-certainty evidence). TCCMD may modestly increase health service utilisation (RR 1.17, 95% CI 1.04 to 1.31; low-certainty evidence), but there was substantial heterogeneity (I2 = 85%), with mixed results according to type of service utilisation (i.e. attendance for STI testing; HIV treatment; voluntary male medical circumcision (VMMC); VMMC post-operative visit; post-abortion care). For health and well-being outcomes, there may be little or no effect on CD4 count (mean difference 13.99, 95% CI -8.65 to 36.63; low-certainty evidence) and a slight reduction in virological failure (RR 0.86, 95% CI 0.73 to 1.01; low-certainty evidence). TCCMD versus non-digital TCC No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may modestly increase in service attendance overall (RR: 1.12, 95% CI 0.92-1.35, low certainty evidence), however the confidence interval encompasses benefit and harm. TCCMD versus digital non-targeted communication No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may increase service utilisation overall (RR: 1.71, 95% CI 0.67-4.38, low certainty evidence), however the confidence interval encompasses benefit and harm and there was considerable heterogeneity (I2 = 72%), with mixed results according to type of service utilisation (STI/HIV testing, and VMMC). Few studies reported on unintended consequences. One study reported that a participant withdrew from the intervention as they felt it compromised their undisclosed HIV status.

AUTHORS' CONCLUSIONS

TCCMD may improve some outcomes but the evidence is of low certainty. The effect on most outcomes is uncertain/unknown due to very low certainty evidence or lack of evidence. High quality, adequately powered trials and cost effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCC delivered by mobile devices. Given the sensitivity and stigma associated with sexual and reproductive health future studies should measure unintended consequences, such as partner violence or breaches of confidentiality.

Effectiveness of One-Way Text Messaging on Attendance to Follow-Up Cervical Cancer Screening Among Human Papillomavirus-Positive Tanzanian Women (Connected2Care): Parallel-Group Randomized Controlled Trial

Background

Rapid human papillomavirus (HPV) DNA testing is an emerging cervical cancer screening strategy in resource-limited countries, yet it requires follow-up of women who test HPV positive.

Objective

This study aimed to determine if one-way text messages improved attendance to a 14-month follow-up cervical cancer screening among HPV-positive women.

Methods

This multicenter, parallel-group randomized controlled trial was conducted at 3 hospitals in Tanzania. Eligible participants were aged between 25 and 60 years, had tested positive to a rapid HPV test during a patient-initiated screening, had been informed of their HPV result, and had a private mobile phone with a valid number. Participants were randomly assigned in a 1:1 ratio to the intervention or control group through an incorporated algorithm in the text message system. The intervention group received one-way text messages, and the control group received no text messages. The primary outcome was attendance at a 14-month health provider-initiated follow-up screening. Participants were not blinded, but outcome assessors were. The analysis was based on intention to treat.

Results

Between August 2015 and July 2017, 4080 women were screened for cervical cancer, of which 705 were included in this trial—358 women were allocated to the intervention group, and 347 women were allocated to the control group. Moreover, 16 women were excluded before the analysis because they developed cervical cancer or died (8 from each group). In the intervention group, 24.0% (84/350) women attended their follow-up screening, and in the control group, 23.8% (80/335) women attended their follow-up screening (risk ratio 1.02, 95% CI 0.79-1.33).

Conclusions

Attendance to a health provider-initiated follow-up cervical cancer screening among HPV-positive women was strikingly low, and one-way text messages did not improve the attendance rate. Implementation of rapid HPV testing as a primary screening method at the clinic level entails the challenge of ensuring a proper follow-up of women.

Trial Registration

ClinicalTrials.gov NCT02509702; https://clinicaltrials.gov/ct2/show/NCT02509702.

International Registered Report Identifier (IRRID)

RR2-10.2196/10.2196/15863

Clients' perceptions and experiences of targeted digital communication accessible via mobile devices for reproductive, maternal, newborn, child, and adolescent health: a qualitative evidence synthesis

BACKGROUND

Governments and health systems are increasingly using mobile devices to communicate with patients and the public. Targeted digital client communication is when the health system transmits information to particular individuals or groups of people, based on their health or demographic status. Common types of targeted client communication are text messages that remind people to go to appointments or take their medicines. Other types include phone calls, interactive voice response, or multimedia messages that offer healthcare information, advice, monitoring, and support.

OBJECTIVES

To explore clients' perceptions and experiences of targeted digital communication via mobile devices on topics related to reproductive, maternal, newborn, child, or adolescent health (RMNCAH).

SEARCH METHODS

We searched MEDLINE (OvidSP), MEDLINE In-Process & Other Non-Indexed Citations (OvidSP), Embase (Ovid), World Health Organization Global Health Library, and POPLINE databases for eligible studies from inception to 3-6 July 2017 dependant on the database (See appendix 2).

SELECTION CRITERIA

We included studies that used qualitative methods for data collection and analysis; that explored clinets' perceptions and experiences of targeted digital communication via mobile device in the areas of RMNCAH; and were from any setting globally.

DATA COLLECTION AND ANALYSIS

We used maximum variation purposive sampling for data synthesis, employing a three-step sampling frame. We conducted a framework thematic analysis using the Supporting the Use of Research Evidence (SURE) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether potential implementation barriers identified in our synthesis had been addressed in the trials included in the related Cochrane Reviews of effectiveness.

MAIN RESULTS

We included 35 studies, from a wide range of countries on six continents. Nineteen studies were conducted in low- and middle-income settings and sixteen in high-income settings. Some of the studies explored the views of people who had experienced the interventions, whereas others were hypothetical in nature, asking what people felt they would like from a digital health intervention. The studies covered a range of digital targeted client communication, for example medication or appointment reminders, prenatal health information, support for smoking cessation while pregnant, or general sexual health information.Our synthesis showed that clients' experiences of these types of programmes were mixed. Some felt that these programmes provided them with feelings of support and connectedness, as they felt that someone was taking the time to send them messages (moderate confidence in the evidence). They also described sharing the messages with their friends and family (moderate confidence).However, clients also pointed to problems when using these programmes. Some clients had poor access to cell networks and to the internet (high confidence). Others had no phone, had lost or broken their phone, could not afford airtime, or had changed their phone number (moderate confidence). Some clients, particularly women and teenagers, had their access to phones controlled by others (moderate confidence). The cost of messages could also be a problem, and many thought that messages should be free of charge (high confidence). Language issues as well as skills in reading, writing, and using mobile phones could also be a problem (moderate confidence).Clients dealing with stigmatised or personal health conditions such as HIV, family planning, or abortion care were also concerned about privacy and confidentiality (high confidence). Some clients suggested strategies to deal with these issues, such as using neutral language and tailoring the content, timing, and frequency of messages (high confidence).Clients wanted messages at a time and frequency that was convenient for them (moderate confidence). They had preferences for different delivery channels (e.g. short message service (SMS) or interactive voice response) (moderate confidence). They also had preferences about message content, including new knowledge, reminders, solutions, and suggestions about health issues (moderate confidence). Clients' views about who sent the digital health communication could influence their views of the programme (moderate confidence).For an overview of the findings and our confidence in the evidence, please see the 'Summary of qualitative findings' tables.Our matrix shows that many of the trials assessing these types of programmes did not try to address the problems we identified, although this may have been a reporting issue.

AUTHORS' CONCLUSIONS

Our synthesis identified several factors that can influence the successful implementation of targeted client communication programmes using mobile devices. These include barriers to use that have equity implications. Programme planners should take these factors into account when designing and implementing programmes. Future trial authors also need to actively address these factors and to report their efforts in their trial publications.

Text Messaging in Oncology: A Review of the Landscape

Text messaging via short messaging service (SMS) is a common route of communication in the United States and offers many advantages to improve health care delivery compared with other forms of mHealth. Text messaging is easy to use, is convenient, is more likely to be viewed than e-mail, and can be tailored to an individual recipient's needs. Despite evidence that patients with cancer desire more mobile-based communication, there are few examples of successful text messaging interventions in the literature. This narrative review examines the current landscape of SMS-based interventions across the continuum of cancer care, including addressing behavioral change, attendance to screening and follow-up appointments, adherence to treatment, and assessment of symptoms and quality of life. Finally, we explore some of the barriers to implementation of a successful text messaging intervention.

The 'Be Cancer Alert Campaign': protocol to evaluate a mass media campaign to raise awareness about breast and colorectal cancer in Malaysia

Background

Breast and colorectal cancer are the two most common cancers in Malaysia. Low awareness coupled with stigma and erroneous beliefs delay help-seeking behaviours, lead to late presentation and contribute to poor detection rates. Promoting cancer awareness through mass media may be effective in improving cancer-related knowledge and uptake in screening tests. However, research is sparse regarding the cultural translation and implementation of mass media campaigns in Malaysia (and Asia) in terms of raising awareness about colorectal and breast cancer.

Methods

A collaborative partnership comprising researchers from Malaysia and the UK as well as policy makers, public health experts and non-government organisations from Malaysia was formed to design, deliver and evaluate the Be Cancer Alert Campaign. Each awareness-raising campaign will run for five weeks (Colorectal Cancer in April 2018, followed by Breast Cancer in October 2018). Evaluation of the campaigns will take place in Gombak district (Colorectal Cancer) and Petaling district (Breast Cancer) respectively, in the form of a pre-post randomly selected household survey and collection of service utilisation data. Occupants who are aged 40-years and above and are able to answer questions independently will be selected from each household. A sample of 730 with 80% power will detect a change of 6.09% in knowledge that unexplained lump or swelling is a symptom of breast cancer or changes in bowel habits is a symptom of colorectal cancer.

Discussion

Malaysia and most South-East Asian countries have a low middle-income economy, with limited resources for cancer control. Late-staged cancers impose a significant economic burden on patients, households, communities, employers, health systems and governments. Our proposed strategy for the implementation of the culturally sensitive mass media cancer awareness-raising campaign will serve as a blueprint for cancer prevention and control policy in South-East Asian countries where the burden of cancer is increasing and there are high cancer death rates.

Effect of cervical cancer education and provider recommendation for screening on screening rates: A systematic review and meta-analysis

Background

Although cervical cancer is largely preventable through screening, detection and treatment of precancerous abnormalities, it remains one of the top causes of cancer-related morbidity and mortality globally.

Objectives

The objective of this systematic review is to understand the evidence of the effect of cervical cancer education compared to control conditions on cervical cancer screening rates in eligible women population at risk of cervical cancer. We also sought to understand the effect of provider recommendations for screening to eligible women on cervical cancer screening (CCS) rates compared to control conditions in eligible women population at risk of cervical cancer.

Methods

We used the PICO (Problem or Population, Interventions, Comparison and Outcome) framework as described in the Cochrane Collaboration Handbook to develop our search strategy. The details of our search strategy has been described in our systematic review protocol published in the International Prospective Register of systematic reviews (PROSPERO). The protocol registration number is CRD42016045605 available at: http://www.crd.york.ac.uk/prospero/display_record.asp?src=trip&ID=CRD42016045605. The search string was used in Pubmed, Embase, Cochrane Systematic Reviews and Cochrane CENTRAL register of controlled trials to retrieve study reports that were screened for inclusion in this review. Our data synthesis and reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). We did a qualitative synthesis of evidence and, where appropriate, individual study effects were pooled in meta-analyses using RevMan 5.3 Review Manager. The Higgins I² was used to assess for heterogeneity in studies pooled together for overall summary effects. We did assessment of risk of bias of individual studies included and assessed risk of publication bias across studies pooled together in meta-analysis by Funnel plot.

Results

Out of 3072 study reports screened, 28 articles were found to be eligible for inclusion in qualitative synthesis (5 of which were included in meta-analysis of educational interventions and 8 combined in meta-analysis of HPV self-sampling interventions), while 45 were excluded for various reasons. The use of theory-based educational interventions significantly increased CCS rates by more than double (OR, 2.46, 95% CI: 1.88, 3.21). Additionally, offering women the option of self-sampling for Human Papillomavirus (HPV) testing increased CCS rates by nearly 2-fold (OR = 1.71, 95% CI: 1.32, 2.22). We also found that invitation letters alone (or with a follow up phone contact), making an appointment, and sending reminders to patients who are due or overdue for screening had a significant effect on improving participation and CCS rates in populations at risk.

Conclusion

Our findings supports the implementation of theory-based cervical cancer educational interventions to increase women’s participation in cervical cancer screening programs, particularly when targeting communities with low literacy levels. Additionally, cervical cancer screening programs should consider the option of offering women the opportunity for self-sample collection particularly when such women have not responded to previous screening invitation or reminder letters for Pap smear collection as a method of screening.

Text Messaging Interventions on Cancer Screening Rates: A Systematic Review

BACKGROUND

Despite high-quality evidence demonstrating that screening reduces mortality from breast, cervical, colorectal, and lung cancers, a substantial portion of the population remains inadequately screened. There is a critical need to identify interventions that increase the uptake and adoption of evidence-based screening guidelines for preventable cancers at the community practice level. Text messaging (short message service, SMS) has been effective in promoting behavioral change in various clinical settings, but the overall impact and reach of text messaging interventions on cancer screening are unknown.

OBJECTIVE

The objective of this systematic review was to assess the effect of text messaging interventions on screening for breast, cervical, colorectal, and lung cancers.

METHODS

We searched multiple databases for studies published between the years 2000 and 2017, including PubMed, EMBASE, and the Cochrane Library, to identify controlled trials that measured the effect of text messaging on screening for breast, cervical, colorectal, or lung cancers. Study quality was evaluated using the Cochrane risk of bias tool.

RESULTS

Our search yielded 2238 citations, of which 31 underwent full review and 9 met inclusion criteria. Five studies examined screening for breast cancer, one for cervical cancer, and three for colorectal cancer. No studies were found for lung cancer screening. Absolute screening rates for individuals who received text message interventions were 0.6% to 15.0% higher than for controls. Unadjusted relative screening rates for text message recipients were 4% to 63% higher compared with controls.

CONCLUSIONS

Text messaging interventions appear to moderately increase screening rates for breast and cervical cancer and may have a small effect on colorectal cancer screening. Benefit was observed in various countries, including resource-poor and non-English-speaking populations. Given the paucity of data, additional research is needed to better quantify the effectiveness of this promising intervention.